Medical Studentsʼ Attitudes toward Patient-centered Care and Standardized Patientsʼ Perceptions of Humanism

Abstract

The physician—patient relationship is central to the delivery of high-quality medical care and has been shown to affect patient satisfaction and a variety of other biological, psychological, and social outcomes. 1 Patient-centered care is one aspect of the physician—patient relationship that takes into account patients' preferences, concerns, and emotions and has been proposed as a mechanism through which favorable patient outcomes are achieved. In recent years, medical educators have recognized the importance of patient-centered care by instituting a variety of curricula to teach communication skills, professional values, and patient-centered behaviors to medical students. 2 Despite the presence of such curricula, we recently demonstrated that medical students have less patient-centered attitudes in later years of medical school. 3 Our quantitative results augment a large body of qualitative and ethnographic data 4–7 that suggest that the culture of medical education emphasizes biomedical issues at the expense of patients' preferences, concerns, and emotions. However, few data exist regarding the clinical significance of students' patient-centered attitudes. Understanding the clinical significance of students' attitudes is critical in the present context of ongoing debate about the relative merits of teaching attitudes versus skills in order to promote greater patient-centered care and improve patients' outcomes. 8 In this study, we explored associations between students' attitudes toward patient-centered care and standardized patients' perceptions of humanism, a construct commonly included in patient-satisfaction outcome measures. Method We employed a cross-sectional study design. We surveyed third-year medical students in the classes of 2000 and 2001 at the beginning of a required family and community medicine clerkship to assess their attitudes toward patient-centered care. During a subsequent clinical performance exam, detailed below, we measured standardized patients' perceptions of students' humanism and compared these perceptions with the students' attitudes regarding patient-centered care. We measured students' attitudes toward patient-centered care using the Patient—Practitioner Orientation Scale, a validated instrument that measures attitudes toward the physician—patient relationship. 9 The Patient—Practitioner Orientation Scale is an 18-item instrument that can be administered to either physicians or patients and measures an individual's attitudes along two dimensions—termed “sharing” and “caring”—using a six-point Likert response scale. The “sharing” dimension consists of nine items that measure the degree to which the respondent believes that power and control should be shared between doctor and patient, and the degree to which doctors should share information with the patient. Examples of sharing items include: “the doctor's agenda is the one that should direct the course of the medical interview” and “often it is in the patient's best interests if he/she does not have a full explanation of his/her medical condition.” The “caring” dimension consists of nine items that measure the extent to which the respondent cares about the value of warmth and support in the relationship, and the degree to which the respondent thinks the doctor should inquire about psychosocial issues and employ a holistic approach to medical care. Examples of caring items include: “a good bedside manner is the most important thing a doctor can bring to a sick patient” and “to understand their patients, doctors must explore relevant sources of stress in their patients' lives.” In normative samples of 131 physicians and 129 non-physician adults, Krupat et al. reported good internal reliability (Cronbach's alpha = .73 and .75 for the two dimensions, respectively). 9 We calculated overall Patient—Practitioner Orientation Scale scores as the mean of the individual item scores; overall scores therefore had a possible range of 1 (“doctor-centered” or paternalistic) to 6 (“patient-centered” or egalitarian). During the family and community medicine clerkship, all students completed a clinical performance exam. During the clinical performance exam, students performed medical interviews with a series of five standardized patients (SPs) who were blinded to the students' Patient—Practitioner Orientation Scale scores and were trained, through standardized training procedures, to portray various clinical issues. These issues included acute headache, routine checkup, chronic pain, hypertension, and smoking behaviors. All SPs except the routine-checkup SP were women. Following the medical interview, each SP completed an eight-item instrument developed by Hauck et al. 10 rating the student physician's humanism. In a normative sample of 185 patients, Hauck et al. demonstrated an internal reliability of .93 (Crohnbach's alpha). 10 Items were rated using a seven-point Likert response scale and included: This doctor seems to take a personal interest in me. Even when my problem is small, this doctor is concerned. I have confidence in this doctor's decisions. This doctor respects my beliefs. I would talk to this doctor if something were troubling me. This doctor takes an interest in my home life. This doctor is easy to talk to. This doctor seems to know what I am going through when I tell him/her about a problem. We calculated an average humanism score for each student as follows: (1) the individual rating from each SP was calculated as the sum of the responses to each item on the humanism instrument (possible range: 8–56); (2) these ratings were converted to percentages by first dividing by 56 and then multiplying by 100 (possible range 14–100); (3) the average score for each student was calculated as the mean of the percentages from the five SPs. Possible scores, therefore, ranged from 14 (low humanism) to 100 (high humanism). Demographic data available to us included each student's gender and the month of the third year during which the family and community medicine clerkship took place. The month of the year reflects the amount of students' previous experience on clinical rotations prior to beginning the family and community medicine clerkship. We used a standard statistical software package to construct linear regression models examining independent associations between Patient—Practitioner Orientation Scale scores, gender, and month of the third year with total humanism scores. We report results below as comparisons of means. Results A total of 293 students completed both the Patient—Practitioner Orientation Scale and five SP interviews. Of these, 120 (41%) students were women and 173 (59%) were men; 151 (52%) students were members of the class of 2000, and 142 (48%) were members of the class of 2001. The mean Patient—Practitioner Orientation Scale score for the overall cohort was 4.58 (SD = 0.46, range 3.17–5.67). The mean humanism score was 81.3 (SD = 7.8, range 53.1–100). Associations between Patient—Practitioner Orientation Scale scores and humanism ratings by SPs are shown in Figure 1. As is demonstrated in the figure, the average humanism score was higher among each successively patient-centered quartile of students. In linear regression analysis controlling for gender and month of the third year, more patient-centered scores were significantly associated with higher ratings of humanism by SPs (p = .01). The mean humanism score for women was 82.7, compared with a mean of 80.4 for men (p = .05). Month of the year during which the family and community medicine clerkship occurred was not significantly associated with the humanism score.Figure 1: Association of overall scores on the Patient—Practitioner Orientation Scale (PPOS) with humanism ratings. The upright bars represent the mean humanism ratings for students who scored in each quartile on the PPOS.Discussion This study provides new evidence to the field of communications training for students and physicians by demonstrating that favorable students' attitudes toward patient-centered care are associated with more favorable patient-defined outcomes in a controlled environment. The humanism construct, defined by Hauck et al. and used in our measure, has been positively associated with patients' satisfaction and greater success in patients' achievement of preventive medicine goals among practicing physicians in the clinical setting. 10 These data collectively point to the need for not only educational interventions aimed toward the communicative and affective skills, but also specific and explicit activities intended to foster more favorable attitudes toward patient-centered care. Unfortunately, our previous work has demonstrated that these attitudes are less patient-centered in later years of medical school. 3 Novack and colleagues have noted that fostering personal awareness among medical students can help by illuminating the personal context around such changes in attitudes. 11 We believe that curricula should also include teaching interventions to directly encourage favorable attitudes toward patient-centered care. Such interventions should make explicit the notion that high-quality care is patient-centered; they should include active role modeling and discussion around role-modeled behaviors, debriefing of seminal events that occur in the clinical teaching arena, and critical framing of patient care activities and communication by learners. 12 While medical school curricula contain courses aimed toward communication and other subject areas where patient-centered attitudes may be fostered, evaluation data are most commonly collected to assess students' skills only (e.g., objective structured clinical examinations and clinical performance exams). While we do not advocate using attitudinal assessments as the basis for forming summative evaluations for individual students, we do believe that the collection of data such as those provided by the Patient—Practitioner Orientation Scale may be useful to educators both in shaping formative feedback for students and in evaluating the success of curricula that are intended to foster patient-centered attitudes. We are currently evaluating the impact of an intervention that provides students with their own Patient—Practitioner Orientation Scale scores, the average score of their medical school class, and normative scores from practicing physicians. During small-group discussion sessions, students are given the opportunity to discuss the meaning of these scores relative to their perceived goals and feelings regarding their future practice of medicine. In our study, the women students received higher humanism ratings than did the men. One explanation is that our standardized patients, the majority of whom were female, had a systematic bias toward rating women students higher in terms of humanism. An alternative explanation, however, is that female students demonstrated greater humanism in the medical encounters; this explanation is consistent with previous work that demonstrates more patient-centered attitudes and communication behaviors among women physicians compared with men. 3,13 Communications curricula should include activities intended to increase sensitivity of students toward styles of communication that differ by gender, ethnicity, socioeconomic status, and other variables that commonly occur in routine medical encounters. For example, such activities may include exercises where students analyze and reflect on sample transcripts of communications between physicians and patients of differing demographic characteristics. Such activities may help to reduce the gender gap that we observed in the humanism scores and that others have noted in clinical care activities such as delivery of preventive services. 14 The reliability of our results for individual students is limited by our use of five standardized patients to measure humanism out-comes. Research on the use of SPs to measure physicians' attributes suggests that 15–20 ratings are generally required to produce reliable estimates. While we demonstrated a statistically significant link between humanism and attitudes in this study, caution should be observed in applying these data to individual students. The generalizability of our results is limited by the fact that our study population was composed of only two cohorts of students at only one institution. Studies in other medical schools with additional cohorts of students and studies that included actual patients whom students have seen in the course of clinical practice would determine whether the association between students' attitudes and patients' outcomes is stable. One aspect that we did not examine in this study was the relationship between students' attitudes, as measured by the Patient—Practitioner Orientation Scale, and students' actual communication skills. It is conceivable that attitudes and skills could be tightly correlated. However, some educators have noted the effect of “performing to the test”; that is, individual students may demonstrate communication skills that they have been taught to perform while believing that such skills are not worthwhile. In such a case, attitude scores may provide insight into a dimension that is not measured by communication skills assessments alone. In our future work, we intend to examine the interplay between attitudes and communication skills as measured by both SPs and attending physicians on students' ward rotations. In conclusion, we have shown more patient-centered attitudes among students to be associated with higher ratings of humanism among standardized patients. Medical school curricula should include specific interventions aimed at attitudes as well as skills. Measurements of both attitudes and skills may be important to assess these curricular interventions and may help to assess the need for additional innovations.